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Based on interview, document review, and review of medical records, it was determined the facility failed to implement the initial discharge plan for the patient. Specifically, the hospital failed to provide written discharge instructions to one (1) of four (4) inpatient records reviewed in the survey sample (medical record #3) and failed to follow its own policy and procedure related to providing discharge instructions to patients.

Findings:

Eight (8) medical records were reviewed in the survey sample. Four (4) of these records were of patients seen in the emergency department and not admitted to the hospital. Four (4) records of patients who were admitted as inpatients and subsequently discharged were reviewed. One (1) of four (4) of the admitted patients' records failed to contain documentation that written discharge instructions were provided to the patient.

The medical record for patient #3 was reviewed and indicated the patient had spinal fusion surgery on 08/11/22 and was admitted to the hospital. The patient was discharged from the hospital on 08/15/22. The patient's medical record contained the following nursing note dated 08/15/22 and timed 7:16 PM: "Patient has been awaiting discharge. [Name of Physician Assistant (PA)] is unable to enter discharge order due to patient has an admission order that needs to be completed. Admitting MD is out of town all week, office stated they are unable to provide assistance. Spoke with nursing supervisor [name] who states ok to let patient go home tonight since PA has entered d/c summary."

The medical record for patient #3 contained a discharge summary authored by the PA that contained documentation of discharge instructions for wound care, diet, activity, follow up appointments, and medications. The medical record contained no documentation that these instructions were provided to the patient prior to discharge.

An interview was conducted with the Chief Medical Officer (CMO) on 10/11/22. The CMO stated that very rarely, a patient will be admitted to the hospital but the order to admit the patient would inadvertently not be signed by the physician. If the order to admit the patient remains unsigned, a discharge order cannot be entered and discharge instructions cannot be generated. Typically, the hospital can call the physician and have them sign the admission order and the discharge can proceed. In this case the physician was unavailable to sign the admission order and the admission order cannot be signed by another physician unless they are part of the same practice.

An interview was conducted with the nurse (staff member #12) who was assigned to the patient on the day of discharge. Staff member #12 stated that the discharge instructions for patient #3 could not be printed. Staff member #12 stated they had never had this issue before. Staff member #12 stated they called the nursing supervisor, the physician's office, and tried "everything I knew how to do on the the computer" but could not get the discharge instructions to print. Staff member #12 stated they handed off report to the night shift nurse who ultimately discharged the patient and was unsure if discharge instructions were ever provided to the patient. The staff nurse who discharged the patient was unavailable for interview. Staff member #12 confirmed that all patients should receive written discharge instructions, education, and medication list at discharge. Staff member #12 stated two packets are printed out. One for the patient to keep and one to be scanned into the electronic medical record. The medical record for patient #3 contained no documentation of signed discharge instructions.

An interview was conducted with the charge nurse on the surgical floor on 10/12/22 who confirmed all patients should be discharged home with discharge instructions and a signed copy should be scanned into the electronic record.

An interview was conducted with patient #3 on 10/11/22 who stated that the hospital did not provide them discharge instructions at discharge. The patient stated that the nurse said, "There is something we need to fix with the instructions and we can't give them to you."

The facility's policy, Discharge of Patients was reviewed and partially reads as follows, "Discharge instruction should be reviewed by a nurse with the patient or significant other. A signed copy of the discharge instructions should be placed in the chart. Discharge instructions will include as indicated: 1. Medications and or prescriptions to include food/drug interactions as appropriate. 2. Activity instructions/restrictions. 3. Nutritional instructions/restrictions. 4. Other instructions as indicated by patient condition. 5. Signs and symptoms to report to the physician. 6. Follow up visit to physician/health care provider....Procedure...2. Review discharge instructions with patient/significant other...Documentation: A. Complete discharge instruction form, discuss with patient/significant other and have signed. B. Complete and discuss medication instruction sheet if indicated. Provide patient with copies of the above."

The above noted deficiency was discussed with Administration staff during the exit conference on 10/12/22.